Renovascular hypertension is the third most common cause of pediatric hypertension (HTN), and if left untreated, risks devastating cardiopulmonary complication, stroke, renal failure, and mortality. The impetus of this study was to identify risk factors responsible for persistent HTN necessitating reoperation. A retrospective analysis was performed of consecutive pediatric patients undergoing open surgical revascularization between 1981 and 2016. Anatomic phenotype and patient risk factors were analyzed using multinomial regression and Kaplan-Meier survival curves regarding perioperative outcomes including blood pressure control, morbidity, and secondary operations. There were 155 patients (70 girls, 85 boys), mean aged 9 years (6 months-19 years), who underwent an index operation, of whom 56 (36%) demonstrated left ventricular hypertrophy by echocardiogram. Thirty patients (19%) had neurofibromatosis, and 70 patients (45%) had abdominal aortic coarctations. Additional diagnoses identified included Williams syndrome, moyamoya disease, fibromuscular dysplasia, Beals syndrome, trisomy 21, Noonan syndrome, gonadal dysgenesis, Alagille syndrome, and Behçet disease. Malignant HTN and failure to thrive were commonly identified at the extremes of youth. Failed previous open or endovascular revascularizations affected 45 children (29%) prior to transfer to the authors' institution. There were 297 primary surgical interventions performed, including renal artery-aortic reimplantation (122), segmental renal artery-renal reimplantation (12), aortorenal bypass most commonly with hypogastric artery (49), segmental embolization (9), renal patch angioplasty (7), and partial or complete nephrectomy (21) in addition to concurrent visceral revascularization (20) and aortic revascularization by way of patch aortoplasty (28) and aortoaortic bypass (29). Surgical morbidity was minimal; renal insufficiency requiring dialysis did not occur. During follow-up that averaged 40 months, 29 children (19%) required reoperation, including both open surgical (22) and endovascular (5) procedures. Those children aged <5 years at the time of index surgery were statistically more likely to require reoperation (P < .05) in comparison to older children (Fig). Children undergoing remedial operations and those with midaortic syndrome were less likely to be cured of HTN. The overall experience revealed HTN to be cured in 67 children (43%), improved in 65 (42%), and unchanged in 21 (14%). There was no perioperative mortality. Contemporary surgical treatment of pediatric renovascular HTN requires an individualized approach providing sustainable benefit to nearly 90% of patients with negligible morbidity and no mortality. Extremes of youth increase the likelihood of reoperation. Patients undergoing remedial surgery and those with abdominal aortic coarctation are less likely to be cured of HTN. Judicious postoperative surveillance is imperative.